OPIOID AGONIST TREATMENT DURING SARS- COV2 & EXTENDED LOCKDOWN: ADAPTATIONS & CHALLENGES IN THE INDIAN CONTEXT

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India went into a lockdown on the 24th of March 2020 to contain the spread of SARS-CoV2 and augment healthcare infrastructure. The lockdown imposed restrictions on both human and vehicular movement and curbed the availability of out-patient based medical services in both public and private sectors. The pandemic, inflicting more than 200 countries, has exposed weaknesses in our public health preparedness and structure of our healthcare systems. However, it has also given an opportunity to learn from each other's experience (Tandon, 2020). The impact of restriction of access to treatment is likely to be disproportionate for patients with substance use disorders (SUD). According to the World Mental Health survey, only 39% patients with SUD recognized a treatment need and 7% received minimally adequate treatment (Degenhardt et al., 2017). A nation-wide survey, published last year, revealed a treatment-gap of 75-80% for patients with drug use disorders (MSJE, 2019). An extended lockdown is likely to widen the treatment-gap further. 1 Existing Opioid Agonist Treatment (OAT) programs in India As per a recent survey, in India there are around 7.7 million people with opioid use disorders and only 25% of those ‘motivated to quit’ received ‘any help,’ which included care in the informal sector, by self-help groups, and other alternative care of medicine (MSJE, 2019). Treatment options for opioid dependence have mainly focussed on abstinence-based strategies. Opioid agonist treatment (OAT) is a relatively recent development in India, the impetus for which was initially provided by the HIV epidemic which was fuelled by the intravenous consumption of heroin. However, the access to opioid agonist treatment (OAT) remains limited. The latest systematic review reported out of 100, only 2-5 individuals who inject drugs receive opioid substitution therapy in India (Larney et al., 2017). There are four sources of OAT in the national healthcare system- a) National AIDS Control Organization (NACO), which was first to initiate large-scale nationwide OAT programs. NACO run OAT program uses plain buprenorphine as directly observed treatment. The number of buprenorphine-based OAT centres run by NACO is 224. NACO has started methadone maintenance clinics as well; b) Drug Treatment Clinics (DTC), started as an initiative of the Drug De-addiction Program (DDAP) under the Ministry of Health; DTCs are physically located in the publicly funded district or general hospitals and are manned by a nurse and a doctor, appointed on contract basis. DTCs have provisions of both buprenorphine and methadone-based treatment. Plain buprenorphine is more commonly used because of its low cost. DTCs follow a daily observed dispensing protocol (Drug De-Addiction Programme, 2018). Presently, there are 22 DTCs; c) Stand-alone, publicly funded addiction psychiatry centres under the Ministry of Health; our centre falls in this category. We have more than 500 registered individuals in our OAT clinic. Take home dosage of buprenorphine-naloxone is dispensed for a period of 1-2 weeks, depending on the stage of maintenance treatment. We encourage takeaways under the supervision (Basu et al., 2020); d) OAT clinics run by the State governments; presently, only the state of Punjab has a buprenorphine-naloxone based Out-patient Opioid Agonist Treatment (OOAT) program, functioning for the last two years. From all the above-mentioned sources, OAT is available free-of-cost. Finally, there are privately funded ‘de-addiction centres,’ which too deliver OAT but the number of such centres are not known and the treatment is expensive. 2 SARS-CoV2 outbreak: adaptations in OAT programs of India Several countries have proposed and implemented modifications in their existing OAT programs in the wake of the SARS-CoV2 emergency. The Substance Abuse and Mental Health Administrations (SAMHSA) of the US has permitted initiation of buprenorphine-based treatment without the need for physical examination, 2-4 weeks of takeaway doses, tele-prescription of agonist medications, and door-step delivery for patients, who are quarantined (SAMHSA, 2020). The Advisory Council on the Misuse of Drugs (ACMD) of the UK has recommended registered pharmacies be enabled to dispense agonist medications, or providing alternative medications (if the prescribed drug has a short-supply), and to give greater number of doses/ takeaway (ACMD, 2020). Changes on the similar lines have been observed in the national guidelines from Norway and Australia. The Indian OAT programs, too, have tried to adapt to the circumstances. The DTCs have permitted bi-weekly or alternate day dispensing for patients maintained on a daily dispensing regime of buprenorphine. Bi-weekly dispensing is allowed only to those patients accompanied by a family member for supervising and safe-keeping of medications. DTCs and NACO run OAT centres have also started takeaway methadone (for one day). The OOAT centres in Punjab have rescheduled the opening hours to 8 a.m., instead of the usual 10 a.m., thus increasing the hours of operation. Kapurthala, an administrative district of Punjab has rolled out a mobile registration and dispensing of agonist treatment under the OOAT program. Our publicly funded centre has brought about several changes in the service delivery- a) increase in the number of doses of takeaway buprenorphine-naloxone (2-4 weeks) thus allowing for less frequent follow-ups; b) we have increased the days and hours of operation as well; c) we have initiated proxy dispensing of buprenorphine-naloxone to a responsible family member. An interim guideline proposed by the Indian Psychiatric Society for opioid substitution therapy during COVID-19 outbreak in India (Indian Psychiatric Society interim guideline, 2020; Basu et al., 2020). 3 Challenges of OAT programs in India during SARS-CoV2 outbreak Both the clients and treatment providers have met with several challenges. 3.1 Clients The availability and access of both buprenorphine and methadone are severely limited because these drugs fall under the category of psychotropic substance and narcotic drugs, respectively, as per the Narcotic Drugs and Psychotropic Prevention Act of India. Although methadone has been brought under the ambit of essential narcotic drugs by an amendment buprenorphine has not figured in the list. Methadone can be stocked and dispensed by any publicly funded “recognized medical institution,” whereas buprenorphine has been approved “for supply to Deaddiction Centres only.” Therefore, neither of these agonist medications is available readily. Hence, clients have to come to the clinics. A large majority of our clients do not have their own conveyance and the public transport system is either non-functional or limited. The two possible alternatives are: tele prescription and door-step delivery. The recently drafted telemedicine guideline does not allow prescription of controlled substances through teleconsultation (Telemedicine Practice Guideline, 2020). The door-step delivery of controlled substances too is not approved by the law. Several clients have reported to us that they were intercepted by the police at the state borders. In all the cases they were required to show their out-patient records to prove the genuineness of their reason to travel during lockdown. This practice impinges upon the privacy and confidentiality of this vulnerable group. 3.2 Treatment providers The movement restriction has unduly affected the staff mobility to the clinics. For our clinic, all the professional and support staff are provided with ‘special passes’ to ensure free movement within and outside the city. In spite of these measures, some staff have still faced questioning while crossing the state borders. The scarcity of personal protective equipment is another perpetual issue. Maintaining adequate physical distance among clients is an important consideration in crowded out-patient settings. Finally, short-supply of agonist medications, in view of non-functioning postal service is creating further challenges. 4 Lessons learnt about the OAT programs in India during SARS-CoV2 outbreak 4.1 Increasing availability In India, there is a gross mismatch between the people in need for OAT and people receive it. There are a handful of centres and mechanisms to deliver OAT, which are geographically scattered, forcing clients to travel far and wide. The pandemic has unmasked this problem by superimposed travel restrictions. India needs more centers, more trained professionals, and investment from the government. 4.2 Increasing the access to treatment It is essential to develop alternative and more accessible models of OAT delivery such as, the mobile dispensing, doorstep delivery, and postal delivery of medications. However, one should be cognizant of measures to minimize misuse and harms. 4.3 Improving the acceptability The pandemic has shown us adaptation and flexibility are the keys to OAT program. Allowing take-away and dispensing medications for longer durations could improve the acceptability of the treatment. These measures should be tested systematically to examine its feasibility and effectiveness. 4.4 Limiting barriers to treatment We witnessed legal and attitudinal barriers for OAT. Advocacy and frequent and multi-pronged public awareness campaigns could minimize these barriers. 4.5 Involvement of stakeholders All stakeholders (clinicians, experts, policymakers, patients, and families) with a common goal of increasing the access, availability, affordability, and acceptability of OAT should come together and build up a consensual action plan to mitigate the challenges and frame a user-friendly OAT policy centred around public health. The pandemic and resultant lockdown is a learning lesson for the policymakers. In spite of the challenges brought about by the unprecedented lockdown, the OAT programs in India are trying to adapt to the emergency by devising locally relevant and practical guidelines. Financial disclosure None. Declaration of Competing Interest The authors report no declarations of interest.

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COVID-19 and Human Mental Health Preserving Humanity: Maintaining Sanity, and Promoting Health

Rajiv Tandon (2020)

In the midst of chaos, there is also opportunity- Sun Tzu As the COVID-19 pandemic rages on, the enormous magnitude of the devastation that it has wreaked across the world is becoming apparent. There are over 5 million confirmed cases of SARS-CoV-2 infection and over 325,000 deaths attributed to COVID-19 distributed across 213 countries/territories and the world economy has plummeted into a deep recession. As nations around the world begin to slowly reopen their economies and gradually emerge from lockdowns/shelter in place, there is a stark realization that SARS-CoV-2 continues to attack us and that we are, at best, nearing the end of the first quarter of this war against the virus. Thus far, most of our efforts at containing the direct health effects of the virus have been directed at flattening the curve. We are slowly beginning to come to terms with the scale of the “collateral damage” to all aspects of our life caused both by the pandemic and our response to it (school closures, workplace closures, stay-at-home restrictions, cancellation of public events, restrictions on socialization and public gatherings, restrictions on international and internal travel, etc.). Experts are now predicting a “tsunami of psychiatric illness”, with the Secretary-General of the United Nations (Guterres, 2020), the Director-General of the World Health Organization (Ghebreyesus, 2020), and the President-Elect of the World Psychiatry Association (DeSousa et al., 2020) calling attention to this impending mental health crisis. Although definitive information is lacking, rates of suicide, substance use disorders, domestic abuse, anxiety and depressive disorders are already reported to be increasing around the world In my last editorial (Tandon, 2020), I had committed that the Asian Journal of Psychiatry would strive to play its role in the dissemination of good information relevant to COVID-19 and mental health. At that time (early March, 2020), we had received 10 articles and published four on the topic. When in the editorial, I invited additional articles with the promise of an expeditious review, little did I realize that we would receive over 550 submissions related to COVID-19 over a 6-week period. We publish 52 articles on the subject in this issue (Volume 51). I want to thank all the authors for their work on the topic, including those whose manuscripts were not accepted for publication and the many reviewers who enabled a fair and rapid review process. In the interests of full transparency, I wish to apprise you about the decision-making process and some key considerations/challenges in this endeavor. 1 The Editor’s Challenge Scientific Journals are a medium of communication between authors and readers. The editorial process serves an intermediary function with the objectives of facilitating transmission of valid, useful knowledge while screening out poor quality or irrelevant material (Tandon, 2014). In an international healthcare crisis such as the COVID-19 pandemic, real-time dissemination of accurate information becomes critical in order to enable healthcare and policy decision-making in a situation of urgency with substantial uncertainty. This compels the Editor to adjust the balance between comprehensive and speedy manuscript processing in order to make valid information available expeditiously (Rankupalli and Tandon, 2010). 2 Modifications in Review Process In order to facilitate an expeditious, yet rigorous and fair process, I initially sent copies of each manuscript to two reviewers who were asked to peruse the manuscript and provide cursory feedback within two days- grade articles from i-iv: (i) definitely publish/(ii) probably publishable/(iii) marginal/(iv) do not publish based on their assessment of relevance, originality, and quality. I read each of these manuscripts and limited my initial editorial decision to (a) accept as is; (b) needs minor revisions without a more detailed review; (c) obtain formal extensive reviews; (d) reject with invitation to resubmit in a more concise format; or (e) desk reject. I based this determination on the input from the two reviewers who perused the manuscript along with my own assessment of the article with the additional consideration of breadth of coverage. If the initial decision was (b) minor revisions without review, I immediately sent a decision letter to the authors with specifics about recommended revisions. If the initial decision was (c) need for formal extensive review, reviewers were promptly identified and asked to submit their reviews within a week. Within two days of receipt of revised versions, an editorial decision was made (accept, revise, reject). Next steps in article processing were promptly initiated. This process worked well for the first 400 articles with initial editorial decisions for all being made within a week of submission. The median time for the 52 accepted articles in this volume to be on line from their date of submission was 10 days. I was unable to maintain this pace for about the past two weeks, but we have now resumed our ability to make initial editorial decisions within a week. An additional editorial challenge was the receipt of a large number of manuscripts of variable quality and relevance. Authors understandably responded to the opportunity and sense of urgency of the situation by seeking to share preliminary experiences, hastily gathered data, or partially developed ideas with the field at large. In addition to the review process outlined above, authors of potentially useful but preliminary or opinion-laden submissions were asked to condense their manuscripts into a more concise format such as Correspondence – along with content, the format helps readers recognize the less definitive nature of the contribution. While publishing a large number of Letters to the Editor has downstream effects such as lowering our Impact Factor, we believe that this was the right course of action. Finally, there appears to be an increased risk of duplicate publication- one of the accepted manuscripts had to be retracted from this volume for this reason. While this form of self-plagiarism is uncommon (Mohapatra and Samal, 2014), authors are reminded that ethical standards of scientific publishing do not become any less rigorous during global healthcare emergencies and this Journal remains vigilant in guarding against any form of scientific misconduct. One downside of our revised editorial process was the increase in the proportion of desk rejections of articles (after preliminary reviewer input) with the inability to provide their authors with detailed reviewer comments- though unavoidable in the context of rapid processing of such a large volume of manuscripts, I do want to acknowledge this shortcoming. 3 Journal Innovations and Looking Ahead We considered a special issue exclusively on COVID-19 and mental health but decided against it for two reasons. COVID-19 is still raging and its mental health consequences will unfold over time, and this necessitates not one-time but continuing coverage of the topic. Of greater import, other mental health problems have not gone away and our relative inattention to them in the context of our almost single-minded attention to the COVID-19 pandemic may worsen morbidity and mortality associated with them. In this volume, the Journal introduces a new article format called Perspectives. Experts are solicited to author a commentary on a topic of high import and relevance. In volume 51, three eminent physician-scientists (Jenson, 2020; Keshavan, 2020; and Patel, 2020) present their outlook on three different topics relevant to COVID-19 and mental health. With distinct points of view, they share their thinking about the mental health impact of the pandemic, our response, the challenges, and opportunities. In the next volume, there will be several reviews and perspective pieces on a range of topics relevant to COVID-19 including: (i) opportunities and challenges of telepsychiatry and mental health apps; (ii) learnings from previous viral outbreaks- what we can and cannot learn from history; (iii) experience of residency training during this time and risks of moral injury and resilience; (iv) impact of the pandemic on people in Asia, differences in national response and their effects across the 50+ nations across Asia (Tandon and Nathani, 2018); (v) misguided dichotomization of health versus economy; (vi) neurobiological and mental health effects of SARS-CoV-2 and the body’s response to the infection; (vii) bioethical considerations in addressing mental health challenges in the context of COVID-19; (viii) mental health problems and appropriate interventions for the general population and vulnerable groups- healthcare workers, persons with significant medical comorbidities, the elderly, and those with pre-existing serious mental illness. 4 Learning from Data (with its limitations!) Although pandemics are not new, COVID-19 is unique in terms of the breadth, magnitude, and rapidity of its impact on mankind. People across 200+ countries across the world have simultaneously been impacted over a short period of time with over half the world in a lockdown and all national economies plummeting into a recession. As of today, there have been over 5 million confirmed cases and 325,000 deaths associated with COVID-19 across the world. Although the pandemic originated in Asia (Wuhan, the capital city of the Hubei province in China), it appears to have disproportionately impacted countries in Western Europe and North America. With 60 percent of the world’s population, Asia accounts for 17% of the confirmed cases and 8% of the worldwide mortality associated with COVID-19. There is significant variation in the confirmed occurrence of COVID-19 and associated mortality across countries in Asia (Table 1 ). Table 1 Confirmed Cases of SARS-CoV-2 Infection and Confirmed Deaths due to COVID across Asia- May 20, 2020. Table 1 COUNTRY Confirmed CasesMay 20, 2020 Reported Deaths May 20, 2020 Deaths per 1 million population COUNTRIES FULLY IN ASIA Afghanistan 8,145 187 5 Bahrain 7,886 12 7 Bangladesh 26,738 386 2.3 Bhutan 21 0 - Brunei Darussalam 141 1 2 Cambodia 122 0 - China 82,965 4,634 3.2 India 112,028 3,434 2.5 Indonesia 19,189 1,242 4.8 Iran 126,949 7,183 86 Iraq 3,724 134 3.3 Israel 16,667 279 32 Japan 16,367 768 6 Jordan 672 9 0.9 Kazakhstan 6,969 35 2 Kuwait 17,568 124 29 Kyrgystan 1,270 14 2.2 Laos 19 0 - Lebanon 961 26 4 Malaysia 7,009 114 3.7 Maldives 1,186 4 7.4 Mongolia 140 0 - Myanmar 193 6 0.1 Nepal 427 2 0.1 North Korea 0* 0* -* Oman 6,043 30 5.9 Pakistan 45,898 985 4.5 Palestine 398 2 0.4 Philippines 13,221 842 7.8 Qatar 37,097 16 6 Saudi Arabia 62,545 339 10 Singapore 29,364 22 4 South Korea 11,110 263 5 Sri Lanka 1,028 9 0.4 Syria 58 3 0.2 Taiwan 440 7 0.3 Tajikistan 2,140 41 4.3 Thailand 3,034 56 0.8 Timor-Leste 24 0 - Turkmenistan 0* 0* --* United Arab Emirates 26,004 233 24 Uzbekistan 2,939 13 0.4 Vietnam 324 0 - Yemen 184 30 1 COUNTRIES PARTLY IN ASIA & EUROPE/AFRICA Armenia 5,271 67 23 Azerbaijan 3,631 43 4 Cyprus 922 17 14 Egypt 14,229 680 7 Georgia 713 12 3 Russia 308,705 2,972 20 Turkey 152,587 4,222 50 Comparison of these statistics across countries is problematic because of the many differences in methods of ascribing deaths to COVID-19, significant differences in rates of testing for SARS-CoV-2 infection, varying quality of data collection and aggregation, and questions about the accuracy of official reporting across countries. Additionally, relative numbers continue to change across the world as the viral pandemic is at different stages of evolution. But these are the only numbers we have and with the caveat of the need for extremely cautious interpretation, some trends are worth noting: a) Iran is the only nation fully in Asia that is among the top 10 countries with the highest number of confirmed cases (#10). Russia and Turkey (two countries partly in Asia) are #2 and #9 when countries are ranked in order of the number of confirmed cases. The other countries are in Western Europe and the Americas. b) In terms of COVID-19 associated per-capita mortality, countries in Western Europe (Spain, Italy, United Kingdom, France, and Germany in that order) and North America (United States of America and Canada) have the highest rates that exceed those in any country in Asia- Iran has the highest mortality rate in Asia followed by three other countries in West Asia (Israel, Kuwait, and the United Arab Emirates). c) The manner in which the SARS-CoV-2 infection spread into and across various countries and their approach to managing the COVID-19 pandemic has differed substantially. Within the significant constraints of the data, available information suggests: (i) An early aggressive containment strategy (in East Asia as in South Korea, Singapore, and Taiwan; perhaps China after initial delays in Wuhan) or an early aggressive mitigation strategy (as in South Asia) may have reduced infection rates and mortality related to COVID-19; (ii) The younger average age of populations in most Asian countries compared to Western Europe likely was an important factor in observed lower mortality rates in Asia. The average age in Japan, however, is comparably high and yet mortality rates there were low; (iii) Colder temperatures (higher latitude) may have been a factor in the different outcomes in Asia versus Western Europe and North America, although Beijing in China has the same latitude as New York in the USA; (iv) South-East Asia (via ASEAN) and South Asia (via SAARC) attempted regional cross-national approaches to supplement national containment/mitigation strategies and this may have contributed to better outcomes in those groups of countries thus far; (v) As in all countries, the elderly and those with comorbid chronic medical illnesses had the worst outcomes and the highest mortality; (vi) In Kuwait and the United Arab Emirates, a disproportionate number of confirmed cases and COVID-19 associated deaths have occurred among migrant workers. Migrant workers in other Asian countries have also experienced relatively worse outcomes than indigenous or non-migrant populations, suggesting that they also constitute a more vulnerable group. While it is imperative that we do not over-interpret or read too much into the data, we can begin learning some lessons relevant to addressing mental health needs of different affected populations. 5 The Opportunity Amidst Tragedy and Uncertainty The pandemic has exposed weaknesses in our public health preparedness and structure of our healthcare systems. The paradoxically worse outcomes in better developed countries with seemingly stronger healthcare systems (Western Europe and North America) warrants careful examination. At a minimum, we have learned that we are all vulnerable and must share the global responsibility of addressing the worldwide shared vulnerability to infectious diseases with pandemic potential. It is notable that we have thus far failed to learn from the previous viral outbreaks of this century (H1N1 and SARS influenza; Ebola, MERS, etc.) - common vulnerability, our weak existing global outbreak surveillance system, and the virtues of an integrated global response. In contrast to the better coordinated international response to the Ebola outbreak, for example, there has been a glaring absence of effective global leadership during this pandemic and this has been extremely costly. Instead of collective problem-solving, nations are engaging in punitive blame games. While mistakes have certainly been made by several parties, a global pandemic calls for a global solution and global collaboration. We are in this together. Additionally, there is a lot of misinformation which increases distrust and fear, adds to the uncertainty, and further clouds decision-making. As clinicians and scientists, we have an important responsibility to combat conspiracy theories and rumors while promoting dissemination of accurate information of what we know, what we don’t know, and what this information means. As societies begin to reopen from their lockdowns, we must make decisions that minimize lives lost (from all causes) and also recognize that there is no dichotomy between protecting lives and protecting our economy. The pandemic has also exposed glaring health disparities and this should provide an impetus for reducing such inequities. As we get ready to be inundated by the short-term and long-term mental health impact of the continuing COVID-19 pandemic, let us be guided by the best data and learn to apply it with grace, humility and diligence. We owe our patients and our profession no less. The Asian Journal will play its small part. We cannot solve our problems with the same thinking we used when we created them- Albert Einstein

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Opioid substitution therapy with buprenorphine-naloxone during COVID-19 outbreak in India: Sharing our experience and interim standard operating procedure

Debasish Basu, Abhishek Ghosh, B. N. Subodh … (2020)

Coronavirus disease 2019 (COVID-19) has been declared as a pandemic by the World Health Organization on March 11, 2020. It has affected most countries of the world, including India. Both the disease and the unavoidable national response to it have posed unique challenges to our health-care system. A particular vulnerable group of patients is those with opioid dependence maintained on opioid substitution therapy (OST). These patients are pharmacologically dependent on the OST medication (buprenorphine, buprenorphine-naloxone combination [BNX], and methadone) for their healthy functioning and recovery. COVID-19 outbreak, lock-down, and difficult access to medical care, all are likely to induce stress and withdrawal, which is a potential risk for relapse among individuals with opioid dependence, who are anyway more vulnerable due to social, housing, living, and medical conditions. In this context, it is essential to re-strategize the existing OST services to adapt to the challenging circumstances. In this communication, we share our experience and formulate interim standard operating procedures (SOPs) for running a hospital-based OST service utilizing take-home BNX. The challenges, principles to meet the challenges, and interim SOPs are shared as being currently practiced in our center. Individual institutes, agencies, hospitals, and clinics running OST service with BNX can adapt these SOPs according to their characteristics, needs, demand, and resources; so long as, the basic principles are adhered to.

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Abhishek Ghosh

Shubhmohan Singh

Anirban Dutta

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Journal ID (nlm-ta): Asian J Psychiatr

Journal ID (iso-abbrev): Asian J Psychiatr

Title: Asian Journal of Psychiatry

Publisher: Published by Elsevier B.V.

ISSN (Print): 1876-2018

ISSN (Electronic): 1876-2026

Publication date PMC-release: 27 August 2020

Publication date (Electronic): 27 August 2020

Electronic Location Identifier: 102377

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[0005]Drug De-addiction & Treatment Centre & Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, India

[0010]Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh, India

[0015]University at Buffalo, Buffalo, NY, 14260, USA

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[* ]Corresponding author. ghoshabhishek12@ 123456gmail.com

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Publisher ID: S1876-2018(20)30490-1 Publisher ID: 102377

DOI: 10.1016/j.ajp.2020.102377

PMC ID: 7450221

PubMed ID: 32889479

SO-VID: 49f47159-54b4-4d35-a397-f87fbce81d8d

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Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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Date received : 19 August 2020

OPIOID AGONIST TREATMENT DURING SARS- COV2 & EXTENDED LOCKDOWN: ADAPTATIONS & CHALLENGES IN THE INDIAN CONTEXT

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COVID-19 and Human Mental Health Preserving Humanity: Maintaining Sanity, and Promoting Health

Opioid substitution therapy with buprenorphine-naloxone during COVID-19 outbreak in India: Sharing our experience and interim standard operating procedure

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